RSI briefing

Report
Initiative
Runway
Safety
Participants
• EASA
• Airbus
• CANSO
• Embraer
• IFALPA
• ACI
• FAA/CAST
• IATA
• LVNL
• ERA
• Boeing
• Eurocontrol
• DGAC France
• AAPA
• Flight Safety Foundation
• US NTSB
• IFATCA
• AEA
• NLR
• Honeywell
• ALTA
• ALPA
RSI Meetings
1. Initial RSI meeting in Amsterdam 7 and 8 Feb 2007
2. Meeting in Brussels 30 and 31 May 2007
3. Meeting in Toulouse 6 and 7 September 2007
4. Meeting in Miami 9 and 10 January 2008
5. Meeting at NTSB in Washington on 7 and 8 May 2008
6. Meeting at EASA in Cologne on 20 and 21 August 2008
7. Meting in Seattle on 13 and 14 November 2008
8. Meeting in Brussels on 25 and 26 February 2009
9. Steering team meeting at FSF on 16 and 17 April 2009
Definition:
A runway safety issue is any safety issue
that deals with the runway environment (or
any surface being used as a runway) and
the areas immediately adjacent to it (e.g.,
overruns, high-speed taxiways).
Runway Safety Issues
•
Runway Incursions
•
Runway Confusion
•
Runway Excursion
ICAO Definition of Runway Incursion:
“ Any occurrence at an aerodrome
involving the incorrect presence of an
aircraft, vehicle or person on the
protected area of a surface designated
for the landing and takeoff of aircraft.”
2007 runway safety events
- TAROM runway incursion accident (0 fatalities)
- S7 excursion report from MAK (126 fatalities)
- Garuda excursion in Indonesia (21 fatalities)
- TAM excursion (187 fatalities)
- Southwest Airlines Midway excursion report
- Air France A340 Toronto excursion report
2008 Runway Safety Events
- Hewa Bora DC-9 excursion (3 Fatal)
- Kalitta B747 excursion (0 fatalities)
- TACA A-320 excursion (3 Fatal)
- Sudan Airways A-310 excursion (30 fatal)
- Continental excursion in Denver (0 fatalities)
- Several corporate aircraft fatal excursions
8
2008
Runway Safety Data
Total Accidents: 97
(44 Jet/53 TP: all Western and Eastern
built commercial jet and turboprop aircraft, Major or substantial damage)
Total Incursion Accidents: 0
Total Confusion Accidents: 0
Total Excursion Accidents: 38
(39%) - 32
Fatalities
Data Availability
• Runway Incursions
- Good
• Runway Excursions
- Good for Accidents and Incidents
with Damage
• Runway Confusion
- Limited (normally no damage, no
injury, no loss of separation)
1977 - KLM / Pan Am
Los Rodeos Airport, Tenerife,
Canary Islands
USAir Runway Incursion Accident – Los
Angeles: Controller cleared aircraft
to land with another aircraft on the runway.
February 1991
SAS
October 2001
Milan, Italy
Runway Incursions
• Part of the new breed of safety
challenge
- Not a lot of accidents
- Numerous incidents
• Basic Risk Management:
Risk = (Probability) X (Severity)
Runway Excursion:
When an aircraft on the runway surface departs
the end or the side of the runway surface.
Runway excursions can occur on takeoff or on
landing. They consist of two types of events:
Veer-Off: Excursion in which an aircraft
departs the side of a runway
Overrun: A runway excursion in which an aircraft
departs the end of a runway
The Players
•
Aircraft Manufacturers
•
Operators
- Aircrews
- Management
•
Airports
•
ATC
•
Regulators
Manufacturers
•
Safe/reliable aircraft
•
Data and procedures for normal
operations
•
Data and procedures for nonnormal operations
Operators
•
Stabilized approach criteria
•
True no-fault go-around policy
•
Training
•
Decision making
- On approach
- On the runway
Airports
• Airport design
• Lighting
• Approach aids (e.g. ILS, VASI, PAPI)
• Runway design (crown, grooved, porous)
• Runway markings and signage
• Runway clearing/cleaning
• Runway condition measurement
• Runway end safety areas
• Airport ARFF
,
ATC
• Stabilized approach assistance
• Pertinent and timely information
- Weather
- Runway condition
Regulator
• Provide appropriate and
professional oversight
• Stabilized approach requirements
- Approaches with vertical guidance
Runway Safety Products Catalog
Runway Incursion:
Product Title
1. ICAO Runway Safety Toolkit
Originator
ICAO
Type Product
CD and web
2. Runway and Surface Safety
FAA
CD and web
3. Taxi 101
FAA
CD and web
Target Audience
Aircrew, Airports, ATM,
Management
Flight Instructors
Pilot Examiners
Maintenance personnel
4. Runway Incursion Prevention
Program
FAA, ACI,
IATA, PAAST
CD and web
Aircrew, Airports, ATM
5. European Action Plan for the
Prevention of Runway Incursions
Eurocontrol et al CD and web
6. Runway Incursion CAST JSIT
Reports
FAA (CAST)
CD
Aircrews, Airports, ATM
Vehicle drivers
Aircrews, Airports, ATM
7. FAA Runway Safety Website
FAA
Web site
8. Enhanced Taxiway Centerline
FAA
CD and web
9. AOPA Runway Safety Course
FAA, AOPA
Web site
General Aviation Pilots
10. ALPA Runway Safety Course
FAA, ALPA
Web site
Aircrews
11. ACI Airside Safety Handbook
ACI
Handbook
Airports
12. Runway Safety: It’s Everybody’s
Business
FAA
Handbook
Pilots, Controllers
13. Pilot Guide to Runway Safety
Sporty’s
CD
Aircrews, ATM, Vehicle
Drivers
Aircrews, ATM, Airports
General Aviation Pilots
Runway Safety Products Catalog
Runway Excursion
Product Title
1. ALAR Tool Kit
Originator
Flight Safety Foundation
2. Managing Threats and Errors
Flight Safety Foundation
During Approach and Landing:
How to avoid a Runway Overrun
3. Takeoff Safety Training Aid
FAA
Type Product
Target Audience
CD
Aircrews, ATM, Airports
Web
Aircrews
CD and web
Aircrews
Runway Safety Products Catalog
Runway Confusion
Runway Confusion: (Many runway incursion products may be
applicable here)
Runway
Confusion
Safety
Data
Incursion
Excursion
Accident Data
1995–2008
Commercial Aircraft
(Substantial and Major Damage, Western- and Eastern-built
Turbojets and Turboprops)
Jets
Major Substantial
286
372
Total
658
Turboprops
Major
528
Substantial
243
771
1,429 Total Accidents
(of all types, not just runway safety accidents)
Runway Safety
Accident Data
1995–2008
1,429 Total Accidents
Number
Percent of Total
Incursions:
10 (.7/year)
.6%
Confusion:
4 (.3/year)
.3%
Excursions:
417 (29.8/year)
29%
Runway Safety Data
1995–2008
Runway Excursion Data
•
36% of jet accidents
•
24% of turboprop accidents
30 years of Taxiway and Runway Incursion / Confusion Accidents
1996 to 2007
Date
Location
Aircraft Type(s)
Accident
Fatalities /
Serious
Estimated Loss
27 Aug 2006
Lexington, KY, USA
CRJ-100
49 F
$147M + $15M = $162M total
3 Dec 2003
Denver, CO, USA
SA-227 / SA-226
Take off on short runway
26
Taxi collision
0
$0M + $4M = $4M total
31 Oct 2001
Taipei, Taiwan
B-747 / construction
equipment
Runway collision
83 F + 71 S
$250M + $66M = $316M total
8 Oct 2001
Milan, Italy
MD-87/ CJ-2
Runway collision
122 F + 71 S
$366M + $35M = $401M total
25 May 2000
Paris, France
MD-83 / Shorts 330
Runway collision
1F
$3M + $7M = $10M total
1997
Amsterdam,
Netherlands
Quincy, IL, USA
B-747 / grass cutter
Taxiway collision
0
$0M + $3M = $3M total
Be-1900 / Be-490
Runway collision
14 F
$42M + $12M = $54M total
269 Fatal
142 Serious
$808M + $142M = $950M
19 Nov 1996
$95M/year
Prior to 1996
Date
Location
Aircraft Type(s)
Accident
Fatalities /
Serious
Estimated Loss
2 Feb 1991
Los Angeles, CA,
USA
Madrid, Spain
B-737 / Be-1900
Runway collision
34 F
$150M
B-727 / DC-9
Runway collision
93 F + 30 S
$300M
Cranbrook, BC,
Canada
Tenerife, Canary
Islands
B-737 / snow plow
Runway collision
42 F + 5 S
$165M
B-747 / B-747
Runway collision
583 F + 59 S
$1800M
752 Fatal
94 Serious
$2,415M
7 Dec 1983
11 Feb 1978
27 Mar 1977
$120M/year
$100M/year Due to Runway Incursions
Three years of Runway Excursion Accidents
2005 to 2007
Date
Location
Aircraft Type(s)
Accident
9 Nov 2007
Quito, Ecuador
A340
Landed long & tailwind
$200M
26 Oct 2007
Butuan, Philippines
A320
Landed long
$60M
16 Sep 2007
Phuket, Thailand
MD-82
Landed long & fast
17 Jul 2007
Sao Paulo, Brazil
A320
Landed long
17 Jul 2007
Santa Maria,
Columbia
Yogyakarta,
Indonesia
Makassar, Indonesia
EMB-190
Landed long
B737-400
Landed long & fast
B737-400
Landed long
$15M
DC-10
Floated on wet runway
$20M
10 Oct 2006
Barranquilla,
Columbia
Stord, Norway
BAe-146
Landed long
$7M
3 Oct 2006
Tarakan, Indonesia
B737-200
Landed long
$15M
7 Sep 2006
Lagos, Nigeria
B727
Landed long & fast
$10M
9 Jul 2006
Irkutsk, Russia
A310
Thrust reverser
4 Jun 2006
Managua, Nicaragua
DC-10
Landed long
$15M
4 Mar 2006
Surabaya, Indonesia
MD-82
Thrust reverser
$15M
8 Dec 2005
Chicago, IL, USA
B737-700
Late thrust reverser
1F+1S
$35M
2 Aug 2005
Toronto, Canada
A340
Landed long & tailwind
11 S
$235M
1 July 2005
DC-10
Unstable approach
$25M
24 Jan 2005
Chittagong,
Bangladesh
Dusseldorf, Germany
B747-200
Landed long & fast
$60M
8 Jan 2005
Cali, Columbia
MD-83
Landed long & fast
$25M
7 Mar 2007
25 Dec 2006
17 Nov 2006
Fatalities /
Serious
Estimated Loss
$20M
199 F + 11 S
$602M
$37M
23 F + 15 S
131 F
354 Fatal
38 Serious
$52M
$70M
$1,518M
$506M/year
$500M/year Due to Runway Excursions
Runway Safety
Fatality Data
1995–2008
1,429 Total Accidents
492 fatal accidents (33%)
Number of Fatal Accidents (Onboard Fatalities)
Incursions:
5 (129)
Confusion:
2 (132)
Excursions:
34 (712)
Fatal and Non-Fatal Runway Accidents by
Type, 1995 Through 2008
Fatal
Runway Confusion
Non-Fatal
Runway Incursion
Runway Excursion
0
50
100
150
200
250
300
Number of Accidents
350
400
450
Runway Excursions - Type
500
79%
450
400
Counts (n=548)
350
300
250
200
150
21%
FSF RSI - E Weener
100
50
0
3/17/2015
Takeoff
47
Landing
Counts (n=113)
Takeoff Excursions
80
63%
70
60
50
37%
40
30
20
FSF RSI - E Weener
10
03/17/2015
48
Veer Off
Overrun
Landing Excursions - Type
250
53%
47%
Count (n=435)
200
150
100
FSF RSI - E Weener
50
0
3/17/2015
49
Overrun
Veer Off
Takeoff Excursions - Fleet Composition
50.0%
45.0%
41%
40.0%
36%
35.0%
30.0%
25.0%
17%
20.0%
15.0%
10.0%
6%
5.0%
0.0%
Other
Business Jets
Jet Transports
Turboprop
Landing Excursions - Fleet Composition
50%
43%
45%
40%
35%
35%
30%
25%
19%
20%
15%
10%
5%
3%
0%
Other
Business Jet
Turboprop
Jet Transports
Takeoff Excursions – Top 10 Factors
50%
40%
30%
20%
10%
0%
Landing Excursions – Top 10 Factors
40%
35%
30%
25%
20%
15%
10%
5%
0%
Corp/Biz Aircraft vs. Full Fleet - Landing Excursions
60%
Corp/Biz
50%
40%
30%
20%
10%
0%
Full Fleet
Runway Safety Observations
•
Data shows we are being effective in
preventing runway incursion accidents, but
the number of incidents and severity still
indicates a very high risk
•
Data shows runway excursions are the most
common type of runway safety accident (96%)
and the most common type of fatal runway
safety accident (80%)
•
Severity of runway excursions dependent on:
- Energy of aircraft when departing the runway
- Airport layout, geography, and rescue capability
Runway Safety Observations
•
New procedures (e.g., Auckland, NZ) may be
helpful in reducing the risk in some runway
incursion and runway confusion situations –
but not all
•
In the case of runway confusion, many runway
incursion interventions may be useful (e.g.,
moving map)
•
In the case of runway excursions, a major
risk reduction factor is flying a stabilized
approach with landing in the touchdown zone
Basics
-
Stabilized approach with landing in
touchdown zone
Energy = Mass X V2
-
Effect of reverse thrust is significantly
greater on a contaminated runway
-
Calculations and rules are important,
but so is adhering to the conditions
used to calculate them:
* e.g., abort past V1
* Land long, land fast
Top Mitigating Factors
•
A mishandled Rejected Takeoff (RTO)
increases risk of takeoff runway
excursion
–
–
–
–
Operators should emphasize and train for proper
execution of RTO decision
Training should emphasize recognition of takeoff
rejection issues
•
•
•
Sudden loss or degradation of thrust
Tire and other mechanical failures
Flap and spoiler configuration issues
Training should emphasize directional control during
deceleration
CRM and adherence to SOPs are critical in time
critical situations such as RTOs
58
Top Mitigating Factors (cont.)
•
Takeoff performance calculation
errors increase the risk of a takeoff
runway excursion
– Operators should have a process to ensure
proper weight and balance, including error
detection
– Operators should have a process to ensure
accurate takeoff performance data
59
Top Mitigating Factors (cont.)
• Unstable approaches increase the
risk of landing runway excursions
– Operators should define, publish, and train
the elements of a stabilized approach
– Crews should recognize that fast and high on
approach, high at threshold, and fast, long
and hard touchdowns are major factors
leading to landing excursions
– ATC/ATM should assist crews to meet
stabilized approach criteria
60
Top Mitigating Factors (cont.)
•
Failure to recognize the need for
and to execute a go-around is a
major cause of landing runway
excursions
–
Operator policy should dictate a go-around
if an approach does not meet the stabilized
approach criteria
– Operators should implement, and support
no-fault go-around policies
– Training should reinforce these policies
61
Top Mitigating Factors (cont.)
•
Contaminated runways increase the risk
of runway excursions
–
–
–
Aircrews should be given accurate, useful, and
timely runway condition information
A universal, easy to use method of runway
condition reporting should be developed to reduce
the risk of runway excursions
Manufacturers should provide operational and
performance information to operators for the
spectrum of runway conditions they might
experience
62
Top Mitigating Factors (cont.)
•
Thrust reverser issues increase the
risk of runway excursions
– Flight crew application of reverse thrust is
most effective at high speeds
– Flight crews should be prepared for
mechanical malfunctions and asymmetric
deployment
63
Top Mitigating Factors (cont.)
•
Combinations of risk factors (such as
abnormal winds and contaminated
runways or unstable approaches and
thrust reverser issues) have an
undesirable synergistic effect on the risk
of runway excursions
–
–
Airports and controllers should insure that accurate
winds for landing are provided to the aircrew in a
timely manner
Aircrews should use a runway excursion risk
awareness tool to increase their awareness of the
runway excursion risks involved with each landing
64
Top Mitigating Factors (cont.)
•
Establishing and adhering to
standard operating procedures
(SOPs) will enhance flight crew
decision making and reduce the risk
of runway excursions
•
– Management and aircrews should mutually
develop SOPs
– SOPs should be regularly reviewed and
updated by a management and aircrew
team
65
Top Mitigating Factors (cont.)
•
The survivability of a runway excursion
depends on the energy of the aircraft as
it leaves the runway surface and the
terrain it must traverse prior to coming
to a stop
–
–
–
All areas surrounding the runway should conform
to ICAO Annex 14 specifications
All runway ends should have a certified runway end
safety area (RESA) or appropriate substitute (e.g.,
EMAS)
Aircraft rescue and fire fighting (ARFF) personnel
should be trained and available at all times during
flight operations
66
Top Mitigating Factors (cont.)
•
Universal standards related to the
runway and the conditions, and
comprehensive performance data
related to aircraft stopping
characteristics, assist in reducing
the risk of runway excursions
– Regulators should develop global, uniform
standards for runway condition measuring
and reporting, and aircraft performance data
67
Basic Plan
• 3 Critical Items for Success:
1. Identify high risk areas (with data)
2. Develop interventions to reduce the
risk in the highest risk areas
3. Get information out internationally
* On a regionally tailored basis
* In a user friendly format
Report of the Runway Safety Initiative
Reducing the Risk of
Runway Excursions
FSF Goal:
Make aviation safer by reducing the
risk of an accident

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